Planning for a Hair Transplant: What to Expect During the First Session

In our experience, patient expectations are most often influenced by the patient's age, stage of hair loss, and its rapidity. The young patient (those in their 20's) with the memory of their adolescent hairline and density still clear in their minds, are also the ones most susceptible to rapid, significant hair loss and are the patients that need the most time in the education and planning process. Other factors include the person's social situation (such as how he is perceived by significant others), and how he has been dealing with his hair loss (such as using a hair piece or the continuous wearing of a hat). It is incumbent upon the physician to educate the patient and set his expectations correctly, or the patient may never be satisfied.

The patient should not be led to believe that hair restoration surgery will restore what has been lost. In the ideal situation, hair restoration surgery should maintain the patient's adult appearance and give him the same "look" as he would have had if he had simply "matured." The surgery should never attempt to restore the patient's adolescent appearance. At a minimum, it can keep the patient from perceiving himself as being bald. In a patient who is distraught from extensive hair loss, this alone can be a significant accomplishment.

The young, rapidly balding patient poses perhaps the greatest challenge. Even an extensive procedure may not be able to compensate for the loss that can occur during the year it takes for the implants to fully grow. In this patient especially, understanding every aspect of the dynamic nature of the hair loss is critical. The progressive nature of balding, realistic hairline placement, the sparing of the crown, and the possible acceleration of loss from the surgery itself must be clearly explained. If the patient does not grasp each and every one of these ideas, it is better to postpone the surgery. Time is always on the physician's side, since the progression of the patient's hair loss will make each of these issues more tangible to the patient, simplifying the education process.

At the other end of the spectrum, the patient who has been bald for many years is much easier to satisfy since his expectations are generally reasonable, and modest amounts of hair will produce a marked change in his appearance. However, this same patient who has worn a hair piece for many years identifies with this look and is much more difficult to please. Like the very young patient, his reference point is a full head of hair. If this patient's only goal is to be rid of the hair system, it is critical to determine the necessary amount of coverage that would be needed to accomplish this. If this has not been established beforehand, a transplant that might be perfect in every other respect, will be a total failure if the patient still feels compelled to wear his hair piece.

Different problems are presented by patients with more limited hair loss. The person who presents with recent progression from an adolescent hairline (Norwood Class I) to a mature hairline with natural recession at the temples (Class II), should not be transplanted. It should be explained that this evolution is normal and a flat hairline would look unnatural as he ages. In this patient, one should not attempt to "fill-in" the temples. It also may not be appropriate to transplant a young, early Class III patient. However, in an older Class III patient with stable hair loss, above average density, and without a familial history of significant balding, it would be appropriate to blunt the angles produced by the bitemporal recession, but not to eliminate it.

A final issue regarding expectations is related to the time frame in which the patient expects to see the results of his procedure. The normal follicular growth cycle is quite variable. In most patients, the majority of the transplanted hair begins to grow at about 3 to 4 months after surgery, with additional hair appearing over the next several months. In a small percentage of patients, the onset of growth of the bulk of the hair can be seen from 4 to 8 months or more, with additional new hair occasionally appearing up to 18 months after the transplant. Since newly transplanted hair will increase in diameter and in length, in this subset of patients, there may be continued cosmetic improvement for up to two years.

There has been much speculation regarding this so called "delayed growth," and it appears that a number of factors may be contributory. Although still speculative, some of these include: 1) the normal asynchronous nature of human follicular growth cycles, 2) the possible resetting of the growth cycle after the post surgical effluvium (shedding) to a new full cycle, 3) the staggering of hair re-growth after the post surgical shedding, 4) retarded growth as a result of graft trauma such as temperature change, desiccation and crush injury, 5) amputation of the dermal papillae during graft dissection with a time lag for it to regenerate from the bulb, and 6) local factors causing delayed growth, such as the often asymmetric elastotic changes in the skin caused by the sun reaching the unevenly protected balding scalp.

Carefully controlled studies, some of which are already in progress, will be needed to sort out the relative importance of each of these factors. Regardless of the cause, it seems that great individual variability is an integral part of the transplantation process. This must be clearly explained in advance in order to keep our patients from becoming "impatient" after hair transplant surgery.

The Critical Session
Regardless of how many procedures are planned, we feel that one should always regard the first transplant as the critical procedure. The patient views the first session as a statement of future sessions. The first session builds confidence, so it is essential that expectations are met. The first session is the most important, for it is the one that generally establishes the hairline and frames the face. The initial transplant also places hair in a position to camouflage subsequent procedures.

In our experience, for the majority of patients, establishing the frontal hairline is the single most important function of the first procedure. At the outset, the frontal hairline should be placed in its normal, mature position. The hairline in this location should frame the face and restore a balance to the patient's facial proportions in a way that is appropriate for a mature individual. In our opinion, the common practice of creating a hairline significantly above the mature hairline position with the intention of lowering it in a subsequent procedure should be avoided. If the intent is to conserve hair in anticipation of a very limited donor supply, one could still maximize the cosmetic impact of the surgery by creating more bitemporal recession or not extending the transplant as far back toward the crown. However, the position of the mid-portion of the frontal hairline should not be compromised, as this defines the "look" of the individual. Creating a hairline too high (in the hope of conserving donor hair) only accentuates the patient's baldness by enlarging the forehead and distorting the normal facial proportions.

The other major goal of the first session should be to provide coverage to the remaining bald scalp with the exception of the crown. Since the Norwood Class A patients, by definition, do not have hair loss extending into the crown, if possible, their entire bald area should be treated in the first session. The amount of hair needed to cover the front and top of the patient's scalp will obviously vary depending upon the extent of baldness, but there should always be an attempt to cover these areas in the first session, even if the coverage is light. In general, areas of the scalp which already have adequate coverage should not be transplanted. Although the edges of the transplanted area should be blended into the hair bearing skin, too aggressive encroachment may accelerate hair loss and not offer any additional cosmetic benefit. The goal should not be to restore adolescent density, since this is neither necessary from a cosmetic standpoint nor (as we have discussed) mathematically reasonable. Patients desiring adolescent density should be treated the same as those desiring an adolescent hairline. They should be further educated rather than ushered off to surgery.

In general, crown coverage should not be a goal of the first session, but should be addressed after the cosmetically more important front and top have been adequately transplanted. Since the front and top of the scalp are together a single cosmetic unit, the transplant may stop after this area has been treated. The patient can then evaluate for himself the adequacy of coverage from the first procedure, and if he desires more fullness or greater density, a second session can be used to supplement the area transplanted in the first. If crown coverage is attempted in the first session, the patient's options will be much more limited, and the ability to produce an aesthetically balanced transplant might be permanently eliminated. An exception would be patients of Norwood Class III Vertex and Class IV, who are generally over the age of 30, have less risk of becoming extensively bald, and have good donor density and scalp laxity. In these situations, transplanting the crown in the first session can provide modest coverage to the area and will serve to camouflage a limited amount of further crown balding. What should be avoided in these patients is the risky practice of repeatedly transplanting hair into the crown to achieve a high degree of density, as this density can often not be supported as the balding progresses.

Beside the aesthetic issues which make the first session so important, there are many surgical advantages of working on a virgin scalp. In sum, implants can be placed more easily, more securely, and closer together into a normal scalp, since the blood supply and elasticity of the connective tissue are intact. In the donor area, maximum density and scalp mobility as well as the absence of scarring will facilitate a hairline closure. To take advantage of these factors, one should attempt to achieve, in the first session, as many of the patient's goals as possible. In our opinion, what can safely be accomplished in one procedure is best done in one procedure, and should not be spread out over two or more.

When Should a Single Session Transplant be Considered?

A great deal can be accomplished in the first session. However, one must be realistic in anticipating what goals may be achieved with a single surgical procedure and in which patients these goals are possible.

As stated, we feel the main goals for the first session should be: 1) to provide a frame for the face, 2) to provide coverage to the front, and, when appropriate, the top and vertex of the scalp, 3) to have a totally natural appearance.

In general, for the physician to suggest to a patient that he might be satisfied with a single session, he should have relatively stable hair loss. This is especially important in the Norwood Class III, IIIa, IV, and V patients whose own hair contributes to the cosmetic appearance of the front of the scalp. In patients who have little frontal hair, the first procedure may successfully frame the face and provide coverage to the anterior portion of the scalp so that even with further balding, a second procedure would not be immediately necessary. For Norwood Class VI or VII patients in which the front and top of the scalp are adequately transplanted in the first procedure, satisfaction can be achieved in one session, because further expansion of the bald crown is relatively inconsequential. However, if coverage of the crown was attempted, then as the bald crown expands, the centrally transplanted grafts would become an isolated island of hair, and further surgery would be required.

A patient with lighter hair color will also have a greater chance of achieving his goals in one session as these colors reflect light and give the appearance of more hair. In addition, the low contrast with the underlying skin gives the illusion of more hair since the skin serves as a "filler" for the space between the hair shafts. In contrast, dark hair over light skin accentuates any spaces between the strands of hair. Salt and pepper hair works both by reflecting light and by creating another visual detail to detract from areas of sparseness. Certainly any patient who does not possess the genetic attributes of good hair color can easily change the color to complement the surgical procedure.

Wavy hair will generally provide better coverage than straight hair and is beneficial in the transplant. As with hair color, this can be manipulated after the surgery to improve the cosmetic impact of the transplant. Very curly hair, on the other hand can, on occasion, work to the patient's disadvantage if complete coverage of the bald area is not anticipated. Very curly hair may increase the fullness of the transplanted area to such a degree that contrast with any remaining bald area may be accentuated. In addition, very curly hair transplanted to the front and top of the scalp may not be easily combed back to cover a bald crown.

The follicular density in the donor area will also impact the procedure. In patients with high density, there will be more hairs per follicular unit, and thus each implant will contain more hair. In patients with very high density, a significant proportion of implants containing 3 and 4 hairs each can be harvested from the donor area, giving a wonderfully full appearance, even from a single procedure.

Patients with hair of average or above-average diameter will have the best chance of success with one procedure. The cylinder of skin surrounding the follicular unit of a patient with coarse hair is roughly similar to a unit of fine hair; however, the volume of hair is vastly different. The diameter or "weight" of the patient's hair is a huge variable. Whereas density may vary by a factor of 3 fold, hair weight may vary from patient to patient by many times that. Although it is much easier to quantify the density (number of hairs/mm2), rather than the weight of an individual hair, the latter is probably more significant to the outcome of the procedure. Those patients with early balding who have fine, dark hair of high density are very difficult to satisfy in a single session, since the transplanted hair is often viewed against the background of the patient's thick terminal hair population that surrounds the bald area. By contrast, in a similar patient with coarser hair, satisfaction is more easily achieved in a single session.

Contrary to what one might expect, the extensively bald patient, even with low donor density, can often be very satisfied after one procedure. These patients often have very reasonable expectations and after being bald for many years are ecstatic to have hair framing their face, light coverage on top, and "something to comb." In order for expectations to be met in one session, the realities of the supply/demand situation must be taken into account. It is obvious that for individuals in the Norwood Class VI or VII pattern, only light to modest coverage can be achieved in a single session, since the area in need of hair will exceed the total donor supply by a factor of at least 6:1, even under ideal circumstances.

Finally, grooming patterns will also influence the success of a single procedure. Patients who plan to comb their hair to the side rather than straight back will have the appearance of much more fullness. Unfortunately, this hair style will not provide crown coverage. Many patients achieve the "best of both worlds" by combing their hair diagonally backwards.


References:

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